The growing use of electronic evaluation and data management and refinements in the standards make it advisable to clarify ACGME’s expectation for documentation in resident files. The ACGME sitevisitors are required to look for evidence of documentation of resident selection, resident evaluation and verification of prior training for transfer residents. Site visitors do this by reviewing a sample of residents’ files. This summary seeks to provide helpful advice on what they expect to see.

Documentation of prior training for transfer residents

The common program requirements require the program director to “receive written verification of previous educational experiences and a statement regarding the performance evaluation of the transferring resident prior to their acceptance into the program.” A companion requirement stipulates that the director of the resident’s former program must provide this verification upon request. The intent of these standards is to allow the program accepting the transfer resident to prepare an appropriate education plan, and to allow forwarding of the documentation to the pertinent ABMS-member board to confirm board eligibility once the resident completes training.

The expectation for documentation of prior training also applies to residents who complete a preliminary or transitional year, and to residents entering fellowship training at the completion of a core program. In all cases, the RRCs expect documentation of prior training to be included in residents’ files, and the ACGME site visitors will look for this in their sampling of these files. Finally, the ACGME also looks for documentation of undergraduate medical education, and for the presence of current ECFMG certificates in the files of international medical graduates.

Use of electronic resident evaluation systems

A growing number of programs use electronic evaluation systems or data management “suites” for collection, aggregation and presentation of a variety of data related to the administration of residency programs. The ACGME and the RRC Council of Chairs have clarified the expectation for information that should be available during the site visit, with the goal of allowing site visitors to verify the existence of a functioning evaluation process, including discussion of the evaluations with the residents. Evidence of this can be offered either via traditional paper-based evaluation forms or print-outs of electronic evaluations, and evidence these evaluations were reviewed with the resident, such as the residents’ signatures. If the program uses an electronic system, it should always maintain a paper record of the final evaluation at completion of training. For residents with academic or other performance problems, there should be additional hard-copy records, because the electronic evaluation parameters may not be appropriate or sufficient in cases where remediation, probation, non-renewal or dismissal needs to be documented.